Medical and Educational Indebtedness Among US Health Care Workers

This cross-sectional study evaluates medical and educational debt among the US health care workforce and explores factors associated with higher debt burdens.


Introduction
Millions of individuals in the US incur educational and medical debts annually, and health care workers may be particularly vulnerable.Extensive training requirements may lead to high student debt among some health care workers, while nonprofessional health workers may be at risk for medical debt due to low wages and poor benefits.Reports have highlighted hospitals' aggressive debt collection actions, including suing their own employees. 1udies of health care workers' debts have focused primarily on physician student loan debt. 2 We evaluated the educational and medical debt of the US health care workforce and factors associated with higher debt burdens.

Methods
This cross-sectional study analyzed publicly available data from the 2018-2021 Survey of Income and Program Participation (SIPP), a nationally representative longitudinal household panel.The Mass General Brigham institutional review board determined this study was exempt from review.We followed the STROBE reporting guideline.
We compared the medical and educational debts of health care workers (including physicians, registered nurses, nursing aides and assistants, and others; n = 8018, weighted N = 12.6 million) with those of other workers (n = 53 346, weighted N = 83.2 million).To examine the effects of sexism, racism, and other systems of oppression on the distribution of debts, we tabulated the frequency and amount of health care workers' debts stratified by sex, self-identified race and ethnicity, income, education, occupation, health care industry subsector, unionization status, health insurance, and hospitalization in the previous year.Logistic regression models were fitted to estimate the associations between medical and educational indebtedness and these variables.We used SIPPprovided weights and survey procedures to account for the sample design.Data analyses were performed between April 28, 2023, and May 17, 2024, using SAS, version 9.4 (SAS Institute Inc).

Results
The more common among Black health care workers than White health care workers and less common among older and lower-income workers and those with lower education levels (Table 2).

Discussion
US health care workers are more likely than other workers to carry medical and educational debt, collectively owing more than $150 billion.We found that medical debt was more prevalent among women, home health and nursing home personnel, uninsured individuals, and those with recent hospitalization.Educational debts disproportionately burdened Black workers and younger workers and those with higher education.
Educational and medical debts are associated with adverse health outcomes 2,3 and may limit workers' professional mobility; reduce workforce diversity; and discourage personnel from entering lower-paying fields, eg, public health or primary care. 2,4,5Health care workers indebted to their employers may be less able to address patient safety concerns or protect themselves from workplace abuses. 6lf-reported data in the SIPP may be subject to recall bias.The SIPP's top coding of dollar amounts (which varies by debt type and year) may have led to an underestimation of debt size.No information on the creditor initiating the debt was available, precluding analyses of whether workers were indebted to their employer.
These findings suggest that US health care workers bear substantial educational and medical debts.Further research should assess the effect of such debts on the health care workforce and patient care.

Table 1 .
Medical Debt Among US Health Care Workers, 2018-2021 a Abbreviations: FPL, federal poverty level; NA, not applicable; OR, odds ratio.aAlldollaramountsare in 2021 dollars (adjusted using the Consumer Price Index).Due to missing data, some percentages may not sum to 100.The CIs were derived from replicate weights using the Fay modified balanced repeated replication method.bIncludesallindividuals (with and without debt) in the given subgroup.cDerivedfrom a single model that included all health care workers and adjusted for sex, race and ethnicity, age, household income, education level, occupation, health care industry subsector, unionization status, health insurance status, and hospitalization during the year of analysis.dIncludes all individuals not identifying as Asian alone, Black alone, or White alone, or as being of Hispanic, Latino, or Spanish origin.e

Table 2 .
Educational Debt Among US Health Care Workers, 2018-2021 a Includes all individuals working in the health care industry (using Survey of Income and Program Participation industry codes [SIPP]) but not having a SIPP code corresponding to working as a physician, nurse, or aide; this includes phlebotomists, medical records specialists, physical therapists, paramedics and emergency medical technicians, janitors and cleaners who work in a health care setting, and others.
a All dollar amounts are in 2021 dollars (adjusted using the Consumer Price Index).Due to missing data, some percentages may not sum to 100.The CIs and SEs were derived from replicate weights using the Fay modified balanced repeated replication method.bIncluding all individuals (with and without debt) in the given subgroup.c e